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1 EMPLOYMENT APPLICATION Fire Department City of Sterling, Colorado 421 N. 4 th St., P.O. Box 4000 Sterling, CO Phone (970) FAX (970) An Equal Opportunity Employer Name Address First Middle Last Number and Street City State Zip Code Home Telephone # Work Telephone # I hereby make application for the position of with the City of Sterling. I herewith submit the following with this application: 1. Copy of high school diploma or G.E.D. certificate and certificates of any higher education. 2. Copy of Form DD214 from military service, if any, for proper credits. 3. The attached personal history statement completed. I understand that I must file all of the above documents fully and accurately completed or my application may not be considered. Applicant's Signature: Date:

2 CITY OF STERLING FIRE DEPARTMENT APPLICATION APPLICANT'S PERSONAL HISTORY STATEMENT Please print or write legibly in BLACK ink. Instructions: Fill out this questionnaire completely and accurately. All statements in your questionnaire are subject to verification. Incorrect statements may bar or remove you from employment. If space provided is inadequate, add another page and identify additional information by item number. PERSONAL INFORMATION Name Date of Birth First Middle Last Month/Day/Year Give any other names you have used or been known by, and attach a statement giving reasons (if none, so state). Name: Name Address First Middle Last First Middle Last Number and Street City State Zip Code Home Telephone # Work Telephone # Can you, upon employment, submit verification of your legal right to work in the United States and documentation verifying your identity? Yes No What are your hobbies, special skills or abilities? Languages: In spaces below, please list any foreign language(s) you use and check the box that describes your skill level. Read Write Speak Language: Language: Do you object to wearing a uniform? Yes No Do you object to working shifts? Are you aware of any conditions that would prevent you from working 24 hour shifts anytime during the week? Yes No If yes please explain. 2

3 REFERENCES Please list five (5) references who have known you intimately for at least five years. All persons to whom you refer may be asked to appraise your character, ability, experience, personality and other qualities. Do not list relatives, former employers and friends. #1 Name Current Address - city, state & zip Telephone Numbers Home: Work: Business, Occupation or Profession of the above named reference: Years Known #2 Name Current Address - city, state & zip Telephone Numbers Home: Work: Business, Occupation or Profession of the above named reference: Years Known #3 Name Current Address - city, state & zip Telephone Numbers Home: Work: Business, Occupation or Profession of the above named reference: Years Known #4 Name Current Address - city, state & zip Telephone Numbers Home: Work: Business, Occupation or Profession of the above named reference: Years Known #5 Name Current Address - city, state & zip Telephone Numbers Home: Work: Business, Occupation or Profession of the above named reference: Years Known Have you ever been arrested for, pled guilty to, or convicted of a felony offense? Yes No If yes, give particulars below: Offense Location of Arrest Date of Arrest Disposition Have you ever been involved in any type of investigation relating to a crime involving arson? Yes No If yes, please explain. 3

4 Have you ever used, distributed, or possessed any other illegal drugs, opiates, pills, etc., other than by a doctor's orders or while under a doctor's care? Yes No If yes, what were the circumstances? Do you drink alcoholic beverages? Yes No If yes to what degree? EMPLOYMENT RECORD Please list all jobs (including part-time, temporary and voluntary positions) you have held in the past ten years. Military service should be listed in the area following this section. Explain any gaps in the section Experience & Employment. Employer: Telephone: Dates Employed: Employer: Telephone: Dates Employed: 4

5 Employer: Telephone: Dates Employed: Employer: Telephone: Dates Employed: Employer: Telephone: Dates Employed: 5

6 Employer: Telephone: Dates Employed: May we contact the employers you listed on previous pages? If no, please indicate which one(s) you do not wish us to contact. MOTOR VEHICLE OPERATION Please list all drivers licenses you have held, beginning with your current license. Driver s license number Name on license State of Issue Expiration Date Have you ever operated a truck with 3 or more axles? Yes No If yes, When? Where? How long? Please list below all moving traffic citations you have received. Location (City) Approximate Date Nature of Violation Penalty or Disposition 6

7 Have you ever been involved as a driver in a motor vehicle accident within the last 7 years? If yes, please give details for each accident. (Attach additional sheets, if necessary) Accident #1 Police investigation? Location (City/State) Date If yes, what law enforcement agency did the investigation? Injury Non-Injury Did you receive a traffic citation? Accident #2 Police investigation? Location (City/State) Date If yes, what law enforcement agency did the investigation? Injury Non-Injury Did you receive a traffic citation? Accident #3 Police investigation? Location (City/State) Date If yes, what law enforcement agency did the investigation? Injury Non-Injury Did you receive a traffic citation? If your license has ever been suspended or revoked, please give details below (including when, where and why). Have you ever been refused an operator's license by any state? Yes No If yes, please give details. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * EDUCATION BACKGROUND High School graduate or GED? Yes No Circle highest grade completed: (Over) Name & Location of Colleges or Vocational Schools Attended Dates Attended Course of Study Degree or Certificate None Type Year 7

8 List any additional training you have taken or received; for example, armed forces training programs, correspondence courses, work training programs, etc.: List all construction equipment or office machines you can operate; speed where applicable; and any special skills or experience you feel you have: Have you ever served in a military organization of the United States? Yes No If yes please attach a copy of Form DD214. List any disciplinary action taken against you while on active duty military, in the National Guard or reserve unit. Have you ever been discharged or forced to resign from a position due to misconduct or unsatisfactory service? If yes, explain in space below: Were you ever rejected for any fire service position? Yes No If yes please state when, who for, and the circumstances involved. Do you have any experience as a fire fighter, either on a professional or volunteer level? If yes please explain. Yes No If it would become necessary in the course of fire duties to endanger yourself would you have any reluctance to do so? Yes No If yes please explain. In the space provided below, please give your reasons for applying for this position. 8

9 CITY OF STERLING CONSENT AND RELEASE PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I UNDERSTAND THAT IF I AM EXTENDED AN OFFER OF EMPLOYMENT, IT MAY BE CONDITIONED UPON MY SUCCESSFULLY COMPLETING ANY REQUIRED EXAMINATIONS, AND THAT I CAN PROVIDE IDENTIFICATION WHICH VERIFIES MY UNITED STATES CITIZENSHIP OR AUTHORIZATION TO WORK OR REMAIN IN THE UNITED STATES. I CONSENT TO THE RELEASE OF ANY OR ALL MEDICAL INFORMATION AS MAY BE DEEMED NECESSARY TO DETERMINE MY CAPABILITY TO DO THE WORK FOR WHICH I AM APPLYING. I UNDERSTAND THAT IF I AM EXTENTED AN OFFER OF EMPLOYMENT, IT WILL BE CONDITIONAL UPON MY AGREEMENT TO ABIDE BY CITY POLICES. By signing, I am authorizing the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand that: I may be asked to consent to a criminal background screening, sex offender registry check, Social Security Number and address verification. I understand that I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS NOR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE CITY MANAGER HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE CITY MANAGER AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE CITY OF STERLING. I HAVE THE RIGHT TO END MY WORK RELATIONSHIP WITH THE CITY, WITH OR WITHOUT ADVANCE NOTICE. THE CITY HAS THE SAME RIGHT. I have read, understand, and by my signature consent to these statements. Print Name Signature Date This application for employment will remain active for a limited time. Ask Human Resources for details. 9

10 CITY OF STERLING EQUAL EMPLOYMENT OPPORTUNITY QUESTIONNAIRE The City of Sterling would appreciate your assistance in completing this brief questionnaire. The answers will be used solely for the purpose of evaluating and reporting the effectiveness of our recruiting and equal employment opportunity efforts. This form will be held separately from your application and will not be used as a basis for any decisions regarding your employment. COMPLETION OF THIS FORM IS OPTIONAL NAME (please print): Position applied for: Full-time Part-time Seasonal Date of Birth: Sex: Male Female ETHNICITY/RACE: (Check One) No Response American Indian or Alaska Native Hispanic or Latino Black or African American, Not Hispanic or Latino Asian White, not Hispanic or Latino Native Hawaiian or Pacific Islander VETERAN/U.S. MILITARY STATUS Veteran Non-Veteran DISABILITY: None Visual Hearing Physical Learning Other How did you learn about this position? Sterling Journal Advocate South Platte Sentinel Other Newspaper ad Location and name of newspaper City job position Location: City of Sterling Website College/Trade School Location: Eastern CO Workforce Center HR Department Referral name: Relative: Name: Dept./Div.: 10

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